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Ergonomic Assessment Form

The ergonomic assessment form evaluates how well a workstation or task fits the person doing it, covering chair, desk, screen, keyboard and posture for desk workers, and lifting, reaching and repetition for shop-floor tasks. It ends with an action plan to reduce strain before it turns into back, neck or wrist injury.

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[Company Logo][Company Name]

ERGONOMIC ASSESSMENT FORM

Ref. No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Assessed by:: [Assessor Name]
Setting:: [Office / Work from Home / Shop Floor]

Employee Details

Employee Name
Employee ID
Designation
Department
Hours per day at this workstation / task

Discomfort Survey (in the last month)

Body Area	None	Mild	Moderate	Severe
Neck / shoulders
Upper / lower back
Wrists / hands
Eyes / headache
Knees / legs / feet

Part A – Desk and Screen Work

Chair height adjusted; feet flat on floor or footrest
Back supported by chair backrest (lumbar support)
Screen top at or slightly below eye level, about arm's length away
Laptop used with stand and separate keyboard and mouse
Wrists straight while typing; elbows near 90 degrees
No glare or reflection on screen
Frequently used items within easy reach
Regular breaks taken away from screen

Part B – Manual Handling and Repetitive Tasks

Loads within safe weight for one person ([Number] kg)
Lifting done between knee and shoulder height
Trolleys, hoists or lift tables available for heavy items
No frequent twisting or overhead reaching
Work surface at suitable height for the task
Anti-fatigue mats for standing work
Task rotation for repetitive motions
Workers trained in safe lifting technique

Risk Rating

Low – minor adjustments only
Medium – changes needed within [Number] weeks
High – immediate action and specialist referral

Action Plan

Issue	Action	Owner	Cost (₹)	Target Date
[Issue]	[Adjustment / Equipment]	[Owner Name]	[Amount]	[DD/MM/YYYY]
[Issue]	[Adjustment / Equipment]	[Owner Name]	[Amount]	[DD/MM/YYYY]
[Issue]	[Adjustment / Equipment]	[Owner Name]	[Amount]	[DD/MM/YYYY]

Reassessment date

The employee confirms the adjustments were explained and agrees to report any continuing discomfort.

Employee
[Employee Name]
Date: [Date]

Assessor
[Assessor Name]
Date: [Date]

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What this template includes

Part A for desk and screen work
Part B for manual handling and repetitive tasks
Discomfort survey by body area
Simple yes/no checks that non-specialists can use
Risk rating to prioritise fixes
Action plan with low-cost fixes first

When to use it

Setting up desks for new joiners or after an office move
Employees complaining of back, neck, wrist or eye strain
Reviewing work-from-home setups
Assessing assembly line, packing or loading tasks
After a return-to-work clearance with restrictions

How to customise this template

1Use only Part A for offices or Part B for plants, or both for mixed roles
2Add your standard equipment options (laptop stand, footrest, trolley)
3Include a WFH photo-upload instruction for remote checks
4Set the weight thresholds your safety team uses for lifting
5Route equipment requests through admin with cost approval

HR tips

Adjust what exists first (chair height, screen position) before buying
Encourage micro-breaks every [Number] minutes
Rotate repetitive tasks across workers
Reassess after changes to confirm discomfort reduced

Ergonomic risk management supports general duties under the OSH Code, 2020 and related rules; this form is a practical tool and does not replace specialist assessment for high-risk tasks.

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Frequently asked questions

What is an ergonomic assessment?+

It is a structured review of a workstation or task to identify postures, movements or setups that may cause strain, and to recommend changes.

Who can do an ergonomic assessment?+

Trained HR, admin or safety staff can use this form for routine checks; refer complex cases to a physiotherapist or ergonomist.

What is the correct monitor position?+

Generally the top of the screen at or slightly below eye level, about an arm's length away, directly in front of the user.

All 50 posh, workplace safety & compliance →

[Company Logo][Company Name]
COMPLAINT OF SEXUAL HARASSMENT AT THE WORKPLACE
To,
The Presiding Officer
Internal Committee, [Company Name]
[Company Address]
Email: [IC Email Address]

This form is confidential. You may attach additional sheets wherever space is insufficient.
Part A – Complainant Details
Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you
Part B – Respondent Details
Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)
Part C – Details of the Incident(s)
Form · Word
POSH Complaint Form
Download .docx
[Company Logo][Company Name]
POSH TRAINING FEEDBACK FORM
Session Date:
[DD/MM/YYYY]
Trainer:
[Trainer Name]
Batch / Location:
[Work Location]
Your feedback helps us improve. Writing your name is optional. Please do not use this form to report a complaint; contact the Internal Committee at [IC Email Address] or any committee member instead.
Section A – About You (optional)
Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff
Section B – Rate the Session (1 = Poor, 5 = Excellent)
Aspect 1 2 3 4 5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me
Form · Word
POSH Training Feedback Form
Download .docx
[Company Logo][Company Name]
WORKPLACE SAFETY INCIDENT REPORT
Incident No.:
[Reference Number]
Date of Report:
[Date]
Reported by:
[Employee Name], [Designation]
Part 1 – Incident Details
Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department
- Fire / smoke / explosion
- Electrical incident
- Chemical / gas / oil leak or spill
- Equipment, vehicle or machine failure
- Structural failure / falling object
- Injury to person (attach injury report)
- Property damage only
- Other: [Details]
Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)
Part 2 – Immediate Action
Form · Word
Workplace Safety Incident Form
Download .docx
[Company Logo][Company Name]
ACCIDENT REPORT FORM
Report No.:
[Reference Number]
Establishment:
[Company Name], [Work Location]
Date of Report:
[Date]
A. Injured Person
Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)
B. Accident Details
Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time
C. Injury Details
Form · Word
Accident Report Form
Download .docx
[Company Logo][Company Name]
FIRST AID INCIDENT FORM
Form No.:
[Reference Number]
Date:
[DD/MM/YYYY]
Time:
[Time]
Location:
[Work Location]
Person Treated
Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number
Complaint or Injury
- Cut / abrasion
- Burn
- Sprain / strain
- Eye irritation / foreign body
- Fainting / dizziness
- Headache / fever
- Allergic reaction / insect bite
- Other: [Details]
Brief description of what happened
Work-related? (Yes / No)
Body part affected
Form · Word
First Aid Incident Form
Download .docx

Full Name
Employee ID / Contractor / Visitor
Designation
Department
Work Location
Preferred Contact Number
Preferred Email
Best time and way to contact you

Name of Respondent
Designation
Department / Organisation
Work Location
Relationship to you (manager, colleague, client, vendor, other)

Name (optional)
Department
Role level (Staff / Supervisor / Manager)
Employee or contract staff

Date of incident [DD/MM/YYYY]
Time
Shift
Location / area / machine
Department

Description: what happened, in sequence
Persons involved (name, ID, employee / contractor / visitor)
Witnesses (name, contact)

Name
Employee ID / Contractor Name
Designation
Department
Age
Gender
UAN
ESI IP Number (if covered)
Contact Number
Emergency Contact informed (name, time)

Date of accident [DD/MM/YYYY]
Time
Shift and hours worked before accident
Exact place
Activity being performed
Machine / tool / vehicle involved
How the accident happened
PPE being worn at the time

Name
Employee ID / Visitor / Contractor
Department / Company
Age
Contact Number

Brief description of what happened
Work-related? (Yes / No)
Body part affected

[Company Logo][Company Name]

PRE-EMPLOYMENT MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Clinic / Doctor:: [Clinic Name]

Part 1 – Candidate Details (to be filled by HR)

Candidate Name
Date of Birth
Gender
Designation Offered
Department
Work Location
Expected Date of Joining
Job exposures (noise / dust / chemicals / heat / height / driving / night shift / food handling)

Part 2 – Health Questionnaire (to be filled by Candidate)

Question	Yes / No	Details
Any ongoing medical condition relevant to the job?		[Details]
Any surgery or hospitalisation in the last [Number] years?		[Details]
Regular medicines currently taken?		[Details]
Any hearing, vision or breathing difficulty?		[Details]
Any back, joint or mobility issue?		[Details]
Any allergy (medicines, dust, chemicals)?		[Details]
Any workplace adjustment you would like us to consider?		[Details]

Part 3 – Clinical Examination (Doctor)

Form · Word

Pre-Employment Medical Form

Download .docx

[Company Logo][Company Name]

ANNUAL / PERIODIC MEDICAL EXAMINATION FORM

Form No.:: [Reference Number]
Examination Year:: [Year]
Date:: [DD/MM/YYYY]
Examining Doctor:: Dr. [Doctor Name]

Section 1 – Employee and Exposure Details

Employee Name
Employee ID
Designation
Department / Section
Date of Joining
Main exposures this year (noise / dust / chemicals / heat / vibration / night shift / screen work)
Average working hours per week
PPE used regularly

Section 2 – Interval Health History

Since the last exam, have you had…	Yes / No	Details
New or worsening cough or breathlessness?		[Details]
Ringing in ears or difficulty hearing?		[Details]
Skin rashes or irritation?		[Details]
Back, neck or joint pain?		[Details]
Eye strain or headaches?		[Details]
Work injuries or sick leave over [Number] days?		[Details]

Section 3 – Year-on-Year Comparison

Form · Word

Annual Medical Examination Form

Download .docx

[Company Logo][Company Name]

DISABILITY ACCOMMODATION FORM

Ref. No.:: [Reference Number]
Date:: [DD/MM/YYYY]
Classification:: Confidential

Part 1 – Employee Details

Employee / Candidate Name
Employee ID
Designation
Department
Work Location
Reporting Manager

Part 2 – Disclosure (voluntary)

Nature of disability (optional, in your words)
UDID / disability certificate available (Yes / No / Prefer not to say)
Preferred format for communication (large print, email, sign language interpreter, other)

Part 3 – Barriers at Work

Form · Word

Disability Accommodation Form

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Aspect	1	2	3	4	5
Content was clear and easy to understand
Examples were relevant to our workplace
Trainer handled questions well
Duration was appropriate
Language of delivery suited me

Ergonomic Assessment Form

Preview of the form

Employee Details

Discomfort Survey (in the last month)

Part A – Desk and Screen Work

Part B – Manual Handling and Repetitive Tasks

Risk Rating

Action Plan

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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